2014 Conference Recaps

Reducing Unnecessary Readmissions: The New RED (Re-Engineered Discharge) Tool

Michael K. Paasche-Orlow, MD

Michael K. Paasche-Orlow, MD

Dr. Michael Paasche-Orlow discussed ways to reduced hospital readmissions. He focused on what Boston University Medical Center has done to lower these rates. He noted that under the Affordable Care Act (ACA), there are incentives for hospitals to avoid rehospitalization. The goal of avoiding rehospitalization is to improve quality and decrease cost, he said.

Hospital discharges are not standardized and are frequently of poor quality. Too often, pending test results are not followed, workups are not completed, and communication is poor. This leads to lack of follow-up care, adverse events, and readmission. This is especially true for patients with poor communication skills, he said.

“We used talk about fee for service; now we talk about fee for value,” he said. “Literacy is a part of that story. There’s a lot of work to be done to transform our organizations.”

Dr. Paasche-Orlow shared the National Quality Forum’s Re-Engineered Discharge checklist:

  • Ascertain need for and obtain language assistance.
  • Make appointments for follow-up care.
  • Plan for follow up of results from pending tests.
  • Organize post discharge services and equipment.
  • Identify correct medicines and plan for patient to obtain.
  • Reconcile discharge plan with national guidelines.
  • Teach a written discharge plan that patient can understand.
  • Reconcile discharge plan with National Guidelines.
  • Educate patient about diagnoses and medicines.
  • Assess degree of patient’s understanding of plan.
  • Expedite transmission of discharge summary to primary care provider.
  • Reinforce through telephone contact.

Studies have found that using the RED checklist is effective and saves money and he offered illustrations of how to put these items into effect.

Transforming a system takes time, and when introducing teachback, “you have to actually supervise it, observe it, and offer feedback.” When working to transform the system, Dr. Paasche-Orlow encouraged attendees to find people who will embrace the work and engage patients.

Tweets for Health: Using Twitter to Convey Simple Health Messages

From left to right: Kathleen Hoffman, PhD, MS, MSPH, RV Rikard, PhD, Alisa Hughley, MPH

From left to right: Kathleen Hoffman, PhD, MS, MSPH, RV Rikard, PhD, Alisa Hughley, MPH

Hoffman, Rikard and Hughley led a lively interactive session on using Twitter and tweet chat, to communicate with people all over the world.

Twitter is a microblogging platform to access resources you wouldn’t have otherwise — to drive people to your organization’s website, reach experts and stakeholder communities, and connect with them offline. Twitter is also a flexible up-to-the-minute news service; make it whatever you want.

The co-hosts described the culture and language of the twitterverse, including hashtags, retweets, favorites and mentions. They also conducted several activities with the audience, including how to turn a long section into an effective tweet (140 characters or less) with a health literacy focus and setting up an account on tweetchat.com.

They also discussed symplur.com, a measuring company for healthcare tweets, where you can have your hashtags registered and approved at no charge. The company indicates that healthcare tweets are trending upward. Each day, there are 1 million tweets related to healthcare!

Yes It’s Clear… But Is It Effective? Why It’s Important to Get Input and Feedback from Your Intended Audience

Janet Ohene-Frempong, MS

Janet Ohene-Frempong, MS

Janet Ohene-Frempong emphasized that clarity and comprehension are necessary, but they may not be sufficient. If information lacks consumer appeal, readers may ignore it, reject it, and not use it. The only way to make sure materials are effective is to get input from the intended audience, she said. “It’s about how effectively we communicate, and how well people can navigate the information.”

In effective materials, she said, information:

  • Is easy to find
  • Looks easy to read
  • Is easy to read
  • Is easy to understand
  • Seems easy to relate to

To make information easy to relate to, she advised, check with the intended audience before you start a project. “Everybody’s got a story, if we’re willing to ask a good question and listen.”

Find out if the information is:

  • Personally relevant
  • Acceptable and non-offensive
  • Believable
  • Persuasive, convincing
  • Practical and easy to respond to

Listen to what people have to say about their beliefs, hopes and concerns. Then use the information you gather. Acknowledge and address their points of view in the information you provide, she said. “You want to get a sense of who you’re writing for, or producing a video for, and respond appropriately, with compassion,” she said.

Ohene-Frempong gave examples of how to make materials more effective and explained how to plan a writing project.  She also spoke about how much health literacy means to her and the deep impact it can have as “people’s health, and sometimes people’s lives, depend on it.”

Panel on Health Literacy in Public Health Practice: Examples from the Field

From left to right: Cynthia C. Peña, MPH, MSW, Steve Sparks, Bonnie Braun, PhD, Cynthia Baur, PhD (Moderator)

From left to right: Cynthia C. Peña, MPH, MSW, Steve Sparks, Bonnie Braun, PhD, Cynthia Baur, PhD (Moderator)

Panel members spoke about using health literacy in public health contexts. They talked about three successful education programs.

Cynthia Peña talked about a program called Sweet Success. It was developed by the California Diabetes and Pregnancy Program (CDAPP). The program’s goal was to train providers and patients in the area of gestational diabetes. It promoted the best ways to manage diabetes before, during, and after pregnancy, Peña said.

Steve Sparks talked about Health Literacy Wisconsin’s flu program. It was called Let’s Talk about the Flu. The program offered workshops in partnership with trusted organizations. It included a plain-language workbook, a flu prevention kit, and vouchers or access to free vaccines. “We were able to reach people who really needed that shot, and wouldn’t have done it without a little encouragement,” Sparks said.

Bonnie Braun talked about the Smart Choice Health Insurance program. The University of Maryland developed it. The developers made changes based on input from the intended audience. For example, they integrated definitions into text and used a spread layout, she said. Braun noted that buying insurance is confusing for everyone — not just for people with limited health literacy.

Building Bridges: Health Literacy Support for Multi-Cultural Communities

Victoria Purcell-Gates, PhD

Victoria Purcell-Gates, PhD

Victoria Purcell-Gates started off her presentation by discussing the relationship between literacy and culture. “Culture is what holds a group of people together,” and it may include beliefs, language, and more. She showed many examples of literacy in practice. If you study these, you can learn a lot about their culture, she said.

Health literacy is an instance of socially situated literacy, she said. It includes reading, writing, speaking, and listening within the social activity of health. Health literacy is the domain of social activity centered around the maintenance of health, physical fitness, and bodily care. It includes reading prescription or shampoo bottles, filling in a medical form, reading health-related magazines, reading bathroom signs, and keeping a dietary journal, she said.

Health Literacy is embedded in social networks. People learn skills faster if they are taught in the context of real-life literacy activity and they are explicitly taught, she said. “Thinking about health literacy this way is going to deepen our understanding. We talk to a lot of other people about our health — not just our doctor,” she said.

Real-life literacy instruction is when teachers engage their students in reading and writing real-life texts for real-life reasons. Classroom examples include:

  • Reading dosage directions to determine how much to take and how
  • Completing an intake form before an appointment to provide important information
  • Googling a health question to learn an answer
  • Reading lab reports to learn about your health
  • Inquiring about prep requirements for procedure
  • Reading pollution index to see if it’s OK to exercise
  • Making a doctor’s appointment online

In order to build bridges with multicultural students, Purcell-Gates urged practitioners and health literacy teachers to learn the health literacy practices in the lives of their students. “You need to get to know your students — their visions and models of health. Then build activities that build on those,” she said. “Spend time in the community — go to community meetings, wash your clothes in the Laundromat, shop in the stores. It takes time to get past your own preconceptions on what you expect to see. It’s like when you travel in another country: You can’t get everything you need from a guidebook. You need to spend time there.”

10 Attributes of a Health Literate Organization

Russell Rothman, MD, MPP

Russell Rothman, MD, MPP

Dr. Russell Rothman discussed the Institute of Medicine’s 10 Attributes of a Health Literate Organization. He talked about how to put these attributes into practice. He listed health challenges in the U.S. “This is true not just for patients with limited health literacy, but for all of us,” he said.

Low quality of care is caused by many factors, including poor health literacy and health communication skills. One aspect of literacy is numeracy. There has been increasing concern about it, he said. Poor health literacy and numeracy are common. Studies have found that literacy and numeracy are associated with health behaviors, knowledge, and outcomes. Examples include understanding food and medicine labels and diabetes knowledge and control, he said.

Dr. Rothman listed some ways we can communicate better:

  • Use low literacy and picture-based materials
  • Individualize education
  • Teach concepts in a simplified manner
  • Use teach-back technique
  • Address cultural issues
  • Use shared goal setting

Studies have found that these strategies improve health outcomes, he said. But they do have limits: They focus on patient-provider communication, and they often don’t consider larger, system-level challenges related to health literacy.

Dr. Rothman listed the Institute of Medicine’s 10 Attributes of a Health Literate Organization and discussed some measures for assessing if an organization has these attributes. An organization can use these measures to address reporting, accountability, management, quality improvement, and research.

We don’t know yet which measures are the most scientifically valid, he said. “It’s a very young field. We didn’t get a lot of specific details about how they will use the measures.” Dr. Rothman closed by offering next steps for evaluating measures of health literacy. He invited the group to share their own measures.

Tools for Clear Communication: PEMAT and the Clear Communication Index

Cynthia Baur, PhD

Cynthia Baur, PhD

Cynthia Baur presented two tools to evaluate patient education materials — the Patient Education Materials Assessment Tool (PEMAT) and the CDC’s Clear Communication Index (Index), both of which are free. The goals of the tools are to help users ensure their materials are understandable and drive the patient to action.

The PEMAT helps untrained lay and health professionals assess the understandability and actionability of print and audiovisual health information materials. The PEMAT does not assess accuracy, comprehensiveness or cultural appropriateness, or perform readability tests; it is a standardized approach to clarity.

There are two PEMATs:  PEMAT-P for printable materials, with 17 items that address understandability — including content, word choice, visuals and design; and 7 items for actionability — how to use the information and take action. PEMAT-A/V is for audiovisual materials (understandability:  13 items, actionability:  4 items).  Downloadable at www.ahrq.gov/pemat , the PEMAT consists of a user guide and a fillable score sheet, where you rate the material:  Disagree, Agree, N/A, enter the ratings and interpret the scores.

The Clear Communication Index consists of four questions and 20 items based in communication and related sciences that staff can use to develop, assess, and score the clarity of communication materials. With this tool, staff can develop new material or assess an existing one. Materials are scored in seven areas: main message and call to action, language, information design, state of the science, behavioral recommendations, numbers and risk. The CCI can be downloaded at www.cdc.gov/healthcommunication/ClearCommunicationIndex/.

Baur led the audience in learning about Index items, what they mean, and how to apply them. The items incorporate plain language, numeracy, and risk communication principles, as well as core communication concepts such as main message and primary audience. She then applied the Index to some sample materials.

The Power of Field Testing

From left to right: Ryan Miller, MA, Christina Powell, MA

From left to right: Ryan Miller, MA, Christina Powell, MA

Powell and Miller talked about qualitative field testing of materials. This type of field testing focuses on quality and has few participants. The data collected is subjective, personal, and in-depth, they said. They offered tips for conducting qualitative field testing. When choosing a test site, we should think about the ideal type of site and site features. “The test site can be just about anywhere. But make sure it creates an environment of free expression so participants will tell you their opinions. Think about audience, budget, and time frame,” said Powell.

The presenters offered tips for recruiting participants, like asking the site for help, provide incentives, screen people for desired demographics, recruit extra participants, in case of no-shows, get the first names of participants and send reminders. They also offered tips for making a detailed schedule, such as limiting each session to about one hour, and allow extra time for notes, bathroom breaks, snacks, and late arrivals. If you have more than one researcher, hold concurrent sessions to save time. “Have the researchers observe each other so they can align their styles,” said Powell.

The presenters offered guidelines for two types of qualitative field testing: cognitive interviews and focus groups.  Cognitive interviews are conducted one-on-one. The interviewer acts as an observer. Her job is to ask follow-up questions and note nonverbal reactions, the presenters said. “These can help you understand the participants’ perspective and give you thoughtful insights,” Miller said. Focus groups are conducted in a group setting — usually eight to 12 participants. The moderator leads a discussion, rather than just observing. His job is to encourage group interaction, ask follow-up questions, note nonverbal reactions, and make sure no one dominates.

The presenters discussed how to work with interpreters. They talked about how to write field test questions and record answers. They also discussed how to analyze and summarize data and write recommendations. The final report should include participant quotations to illustrate points, they said. “This is often what people look at first or think is most important,” said Miller.

The Power of Digital Storytelling

Robin Smith

Robin Smith

Smith’s session was centered on the power of conveying a story and how we can use these stories to effectively reach and educate our patients.  She believes that while data gathering is important to organizations, it is also important to be able to tell a story because “ultimately you need to put a heart in your data” in order to make an emotional connection to another human being.  She quoted Helen Osborne’s insightful point that “when you tell a good story, you can frame important messages in ways that make them memorable for your listeners.”

Story telling is a “powerful tool to engage, inspire and promote learning”. Smith discussed various ways stories can be gathered and the steps you should take in order to create an effective piece.  She also provided tips on how to identify a good story, how to interview, and how to get the appropriate releases. Furthermore, she outlined the aspects that make up a good story, such as having a Hero, describing their obstacles or why their story is important, and defining a clear beginning, middle and end. One suggestion she provided was to interview your patient or client.  She recommended to audio tape the interview, transcribe the interview and then have it reviewed by a third party.  She also stresses the importance of pictures to capture a visual image of the story.

Smith demystified the process of creating a video story and walked attendees through the steps of creating a powerful video piece. She emphasized how important it is to keep record of the digital stories you collect for purposes such as patient and client education, marketing, training, and advocacy.

From Didactic to Fantastic: Integrating Interactivity into Your Learning Session

Farrah Schwartz, MA

Farrah Schwartz, MA

Consumer health education is often didactic and may not engage participants in learning. Not only can this be boring for learners and for teachers, but this approach has been demonstrated to have poorer learning outcomes than education that uses multiple formats and integrates adult learning strategies.
Interaction in education is easy to do and can help make learning successful. Schwartz provided attendees with simple strategies to integrate interactive activities into their learning to maximize health outcomes, learning retention and engagement.

This interactive session used various engagement strategies starting before attendees walked through the door, and drew on attendees own experiences. Schwartz shared some basic adult learning principles and facilitated discussions to help attendees identify adult learning needs and strategies in a healthcare environment.

Schwartz reviewed some specific interactive techniques that can be used in learning, such as:

  • reflection
  • paired and group discussion
  • audience polling
  • quizzes, games
  • ice breakers
  • the use of multimedia, including digital technology

The session closed with attendees identifying interactive strategies that they will integrate into their teaching over the next 6 months.